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Cited by 213Global Maternal and Child HealthMaternal and fetal healthcareReproductive Health and Contraception

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Maternal Mortality in India: Causes and Healthcare Service Use Based on a Nationally Representative Survey

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Montgomery, Ann L., Ram, Usha, Kumar, Rajesh, Jha, Prabhat, for The Million Death Study Collaborators·2014·PLoS ONE
DOI 10.1371/journal.pone.0083331PMC PMC3893075
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Abstract

BACKGROUND: Data on cause-specific mortality, skilled birth attendance, and emergency obstetric care access are essential to plan maternity services. We present the distribution of India's 2001-2003 maternal mortality by cause and uptake of emergency obstetric care, in poorer and richer states. METHODS AND FINDINGS: The Registrar General of India surveyed all deaths occurring in 2001-2003 in 1.1 million nationally representative homes. Field staff interviewed household members about events that preceded the death. Two physicians independently assigned a cause of death. Narratives for all maternal deaths were coded for variables on healthcare uptake. Distribution of number of maternal deaths, cause-specific mortality and uptake of healthcare indicators were compared for poorer and richer states. There were 10,041 all-cause deaths in women age 15-49 years, of which 1096 (11.1%) were maternal deaths. Based on 2004-2006 SRS national MMR estimates of 254 deaths per 100,000 live births, we estimated rural areas of poorer states had the highest MMR (397, 95%CI 385-410) compared to the lowest MMR in urban areas of richer states (115, 95%CI 85-146). We estimated 69,400 maternal deaths in India in 2005. Three-quarters of maternal deaths were clustered in rural areas of poorer states, although these regions have only half the estimated live births in India. Most maternal deaths were attributed to direct obstetric causes (82%). There was no difference in the major causes of maternal deaths between poorer and richer states. Two-thirds of women died seeking some form of healthcare, most seeking care in a critical medical condition. Rural areas of poorer states had proportionately lower access and utilization to healthcare services than the urban areas; however this rural-urban difference was not seen in richer states. CONCLUSIONS: Maternal mortality and poor access to healthcare is disproportionately higher in rural populations of the poorer states of India.

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Figure 1 2005 estimated proportion and number of maternal deaths by region. Datasource: SRS 2001–3, SRS 2004–6 MMR and UN live birth and death estimates for India 2005 *Unweighted sample count of maternal deaths **Survey weighted, (95%CI), rounded to nearest 100th. MDS - Million Death Study. Low-income states Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Orissa, Rajasthan, Uttar Pradesh, Uttarakhand and Assam.
Figure 1 2005 estimated proportion and number of maternal deaths by region. Datasource: SRS 2001–3, SRS 2004–6 MMR and UN live birth and death estimates for India 2005 *Unweighted sample count of maternal deaths **Survey weighted, (95%CI), rounded to nearest 100th. MDS - Million Death Study. Low-income states Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Orissa, Rajasthan, Uttar Pradesh, Uttarakhand and Assam.CC BY · PubMed Central
Figure 2 Cause of death distribution and estimation of annual number of maternal deaths by cause. Datasource: Indian SRS 2001–3 data, SRS 2004–6 MMR and UN live birth and death estimates for India 2005. ICD-10 categorization of cause of death [14] MDS - Million Death Study aUnweighted sample count of maternal deaths bSurvey weighted, (95%CI), rounded to nearest 100th. cIncludes ill-defined obstetric deaths (n = 205), antenatal and postpartum suicide (n = 24), vascular accidents (n = 16), and uterine inversion (n = 2). dIncludes ‘unanticipated’ anesthetic complications (n = 4). Compare with proportion of unweighted maternal deaths reported with RGI categorization: hemorrhage (38%, estimated total deaths for 2005 = 26 000), other (34%, total = 23 500), sepsis (11%, total = 7600), abortion (8%. total = 5500), obstructed labour (5%, total = 3400), and hypertensive disorders of pregnancy (5%, total = 3400) [1].
Figure 2 Cause of death distribution and estimation of annual number of maternal deaths by cause. Datasource: Indian SRS 2001–3 data, SRS 2004–6 MMR and UN live birth and death estimates for India 2005. ICD-10 categorization of cause of death [14] MDS - Million Death Study aUnweighted sample count of maternal deaths bSurvey weighted, (95%CI), rounded to nearest 100th. cIncludes ill-defined obstetric deaths (n = 205), antenatal and postpartum suicide (n = 24), vascular accidents (n = 16), and uterine inversion (n = 2). dIncludes ‘unanticipated’ anesthetic complications (n = 4). Compare with proportion of unweighted maternal deaths reported with RGI categorization: hemorrhage (38%, estimated total deaths for 2005 = 26 000), other (34%, total = 23 500), sepsis (11%, total = 7600), abortion (8%. total = 5500), obstructed labour (5%, total = 3400), and hypertensive disorders of pregnancy (5%, total = 3400) [1].CC BY · PubMed Central
Figure 3 Proportion of highest healthcare sought by timing of direct maternal death. x-axis: Survey weighted proportion of timing of direct maternal death (n = 919) with respect to the pregnancy: early termination (spontaneous or therapeutic), term antenatal complication (≥7 months), intrapartum, postpartum. y-axis: Highest healthcare sought at onset of complication leading to death: routine admission to health-facility/hospital for abortion or labour, emergency admission for complication, community consultation for complication, no facility-based healthcare utilization at time of complication.
Figure 3 Proportion of highest healthcare sought by timing of direct maternal death. x-axis: Survey weighted proportion of timing of direct maternal death (n = 919) with respect to the pregnancy: early termination (spontaneous or therapeutic), term antenatal complication (≥7 months), intrapartum, postpartum. y-axis: Highest healthcare sought at onset of complication leading to death: routine admission to health-facility/hospital for abortion or labour, emergency admission for complication, community consultation for complication, no facility-based healthcare utilization at time of complication.CC BY · PubMed Central
Figure 4 Uptake of routine and emergency healthcare in poorer and richer states, by rural urban areas. Datasource: Indian SRS 2001–3 data. Graphs A and B for subgroup of women who experienced spontaneous labour onset or arranged a medical abortion (n = 732) (i.e. omitting those for whom a complication arose prior to the need for of routine care). A:Skilled birth attendance comparison of rural and urban area of poorer states (p = 0.0022) and richer states (p = 0.0435) and B: Planned health-facility delivery comparison of rural and urban of poorer states (p = 0.0435) and richer states (p = 0.3061). Graphs C and D for all maternal deaths in the sample (n = 1096). C: Emergency transport comparison of rural and urban area of poorer states (p = 0.0036) and richer states (p = 0.2919) and D: Health-facility admission comparison of rural and urban area of poorer states (p = 0.0001) and richer states (p = 0.4135).
Figure 4 Uptake of routine and emergency healthcare in poorer and richer states, by rural urban areas. Datasource: Indian SRS 2001–3 data. Graphs A and B for subgroup of women who experienced spontaneous labour onset or arranged a medical abortion (n = 732) (i.e. omitting those for whom a complication arose prior to the need for of routine care). A:Skilled birth attendance comparison of rural and urban area of poorer states (p = 0.0022) and richer states (p = 0.0435) and B: Planned health-facility delivery comparison of rural and urban of poorer states (p = 0.0435) and richer states (p = 0.3061). Graphs C and D for all maternal deaths in the sample (n = 1096). C: Emergency transport comparison of rural and urban area of poorer states (p = 0.0036) and richer states (p = 0.2919) and D: Health-facility admission comparison of rural and urban area of poorer states (p = 0.0001) and richer states (p = 0.4135).CC BY · PubMed Central

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Research works printed but not linked: 3

  1. RGI (2011) Special bulletin on maternal mortality in India 2007–09. New Delhi: Office of the Registrar General.
  2. RGI (2009) Special bulletin on maternal mortality in India 2004–2006. New Delhi: Office of the Registrar General.
  3. Cunningham FG, Williams JW (2009) William's obstetrics. New York: McGraw-Hill Education, 23 edition.

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Metadata

Authors
Montgomery, A. L., Ram, U., Kumar, R., Jha, P., & Collaborators, F. T. M. D. S.
Affiliations
  • St. Michael's Hospital (CA)
  • Post Graduate Institute of Medical Education and Research (IN)
Corresponding author
Montgomery, Ann L.
ORCID
Venue
PLoS ONE
Publisher
Public Library of Science (PLoS)
Published
2014-01-15
Volume
9
Issue
1
Pages
e83331
ISSN
1932-6203 (ISSN-L)
DOI
10.1371/journal.pone.0083331
PMC
PMC3893075
OpenAlex
W2035109025
Cited by
213
References
30
Citations by year
2026: 7 · 2025: 13 · 2024: 12 · 2023: 16 · 2022: 18 · 2021: 20 · 2020: 37 · 2019: 19 · 2018: 22 · 2017: 15 · 2016: 19 · 2015: 12 · 2014: 3
FWCI
14.38
Type
journal article
Language
en
Open access
Licence
Locations
  • PLoS ONE (publishedVersion, cc-by)
  • Europe PMC (PubMed Central) (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
  • Greater South Information System
Topics
  • Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Global Maternal and Child Health
  • Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Maternal and fetal healthcare
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Reproductive Health and Contraception
Keywords
maternal mortality, cause-specific mortality, emergency obstetric care, skilled birth attendance, health care utilization, urban-rural differences, state-level poverty, direct obstetric causes, India
MeSH terms
Female, Humans, India, Maternal Mortality, Pregnancy

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